Cause of Recurrent Postoperative Atelectasis after Upper Right Lobectomy without Middle Lobe Torsion
Recurrent atelectasis following upper right lobectomy in the absence of middle lobe torsion can be multifactorial, but the presence of eosinophilia and an elevated immunoglobulin E (IgE) level around 200 IU/mL suggests an underlying allergic or hypersensitivity-mediated pulmonary process, such as allergic bronchopulmonary aspergillosis (ABPA) or an allergic fungal airway disease. This is particularly relevant given the association between eosinophilia, elevated total IgE, and fungal hypersensitivity reactions, especially to Aspergillus species, which frequently colonize damaged or surgically altered lung structures Castro-Fuentes et al. 2026.
The immunological profile with eosinophilia and elevated IgE points to a type 1 hypersensitivity reaction that leads to bronchial inflammation, mucus production, and plugging, causing lobar or segmental atelectasis recurrently despite surgical resection. This aligns with the pathophysiology of ABPA or allergic fungal airway disease, where fungal sensitization triggers eosinophilic inflammation and mucus impaction without invasive infection. Upper lobe localization is commonly seen in such cases Castro-Fuentes et al. 2026.
Also, postoperative structural changes post-lobectomy might predispose to impaired mucociliary clearance, persistent bacterial or fungal colonization, and airway inflammation characteristic of bronchiectasis or chronic suppurative lung disease (CSLD), further promoting recurrent atelectasis Unknown 2018. This could compound the allergic reaction by providing an environment for fungal colonization and immune sensitization.
Management
Management must focus on both the mechanical aspects of lung re-expansion and the immunological control of allergic inflammation.
- Medical Therapy: Initiate systemic corticosteroids to control eosinophilic and allergic inflammation, aiming to reduce bronchial mucosal edema and mucus plugging, thereby relieving atelectasis Castro-Fuentes et al. 2026.
- Antifungal Treatment: Target Aspergillus sensitization with antifungal agents such as voriconazole or isavuconazole, which have proven efficacy in allergic bronchopulmonary aspergillosis and chronic pulmonary aspergillosis; these agents reduce fungal burden and antigenic stimulus Castro-Fuentes et al. 2026.
- Airway Clearance: Implement regular airway clearance techniques consistent with bronchiectasis management guidelines, aiming to improve mucociliary clearance and prevent mucus plugging that can cause atelectasis Unknown 2018.
- Surveillance and Diagnostics: Monitor IgE levels and eosinophil counts to assess response. Imaging with HRCT scans helps to evaluate for bronchiectasis or mucus plugging severity and excludes other structural causes. Bronchoscopy may be considered to remove mucus obstruction or obtain microbial and fungal cultures to guide therapy Unknown 2018 Castro-Fuentes et al. 2026.
- Immunologic Assessment: Evaluate for underlying immunodeficiency or coexisting conditions that may predispose to recurrent infection or allergic inflammation Unknown 2018.
- Adjunctive Therapies: Consider macrolide antibiotics for their anti-inflammatory effects if bacterial infection or colonization is present Unknown 2018.
Overall, these multidisciplinary interventions aim to interrupt the cycle of fungal hypersensitivity, airway inflammation, mucus plugging, and atelectasis following lobectomy. Early identification and treatment of allergic fungal airway disease in this context can prevent progression to bronchiectasis and further postoperative complications Castro-Fuentes et al. 2026 Unknown 2018.